Posts Tagged ‘Zambia’

Lumbar puncture rejections are commonplace in Zambia. GHA blogger, Ifeoma Ozodiegwu, shares some insights on their importance in the prevention of HIV deaths in Zambia.

The woman lay on her side, one arm supporting her head, one eye half closed. She was wearing a blouse and a chitenge wrapper*. Two relatives stood by her side like guardian angels, concern written on their faces. The resident doctor has just recommended that she go through a lumbar puncture. The intern was speaking to the family to get informed consent for the procedure. I stood in the corner and watched. I was volunteering at a Zambian hospital.

The unanimous response from the patient and her relatives was “no”. The intern tried to explain what a “no” meant. The patient needed the procedure to diagnose her condition and it was against the hospital’s policy to treat a patient blindly. I stepped in and joined my voice with that of the intern doctor but they remained adamant. The final answer was negative.

Lumbar puncture rejections are commonplace in Zambia; even in dire circumstances. In a 2009 study, over 90% of the study participants had negative attitudes towards lumbar punctures. Many care seekers associate lumbar punctures with death or paralysis. To compound the issue, a well-known local media organization had also criticized hospitals’ handling of spinal taps stating that, “Countless people have died after having this seemingly simple procedure done”.

What makes Lumbar Punctures Important?

According to the NHS Choices website, Lumbar puncture can be used to detect a variety of health issues like meningitis, subarachnoid hemorrhage and Guillain-Barre syndrome. Lumbar punctures can also be used to administer medication into the cerebrospinal fluid (CSF).

Research has shown that individuals infected with HIV are at increased risk of tuberculosis meningitis (TBM), a serious complication of tuberculosis infection. Given Zambia’s high HIV prevalence, rate physicians recommend lumbar punctures to ensure early detection of TBM, which if left untreated can lead to neurological damage and premature death.

However, this CSF collection technique poses some risks and should not be performed if a patient has a skin infection on the needle entry site or there are unequal pressures within some parts of the brain. A judgment call is required if a patient has an elevated intracranial pressure, a clotting disorder or a brain abscess but the procedure can still be carried out if the risks outweigh the benefits.

I raised my concerns about the risks associated with lumbar punctures with a Zambian resident physician and she said that in her place of practice at a public hospital, efforts are made to ensure that lumbar punctures are safe for patients and CT scans are done prior to a lumbar puncture if they suspect that it will be too risky for the patient. She also mentioned that many patients refuse to undergo a lumbar puncture until they are terminally ill and at that point, the procedure is just a formality as they often pass on afterwards thus fueling misbeliefs.

I tried to research lumbar puncture safety in Zambia and came up with nothing. Therefore, I cannot comment on safety conditions associated with the procedure in Zambia

An Important Message

In the same hospital where I was volunteering, just a few steps behind the lady who refused to have a lumbar puncture done, a dusty sign above her head read “Lumbar Puncture Saves Lives”. This is a message that is so important but it does not seem to filter through to the intended audience. In the fight to prevent premature deaths from HIV in Zambia, NGO, their partners and Governmental Health Agencies need to prioritize the messaging surrounding lumbar punctures. If misconceptions continue and increase, individuals that are co-infected with HIV and TB will not receive the treatment they need, and will risk spreading TB to others in their communities.

Health promotion campaigns, patient counseling and peer advocates are necessary to change the current negative trends surrounding lumbar punctures whereas public and private health facilities need to ensure that lumbar punctures are performed in the best safety conditions to assuage the concerns of their patrons. It will be laudable if a research study can be conducted within Zambian health facilities to quantify the number of lives saved by lumbar punctures and investigate if physicians follow guidelines when performing the procedure. This will inform efforts to strengthen capacity if issues are detected. If the results of the research study are positive, they can be shared with the public to counter existing misconceptions.

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Global Health Africa blogger-Ifeoma Ozodiegwu– shares her experiences in her work with an NGO in Zambia

September 4th 2013 was one of those lucky days for me! I got to visit one of the communities where our Programme for the Awareness and Elimination of Diarrhoea (PAED) works in Zambia. Diarrhoea is the 3rd largest killer of children under the age of 5 in Zambia. One of the pillars of the PAED program is the promotion of practices that prevents diarrhoea-related illness and death. Community Led Total Sanitation (CLTS) is a diarrhoea preventive practice that advances handwashing and the use of toilets to stop open defecation. The mission of the PAED Team was to implement a Community-Led Total Sanitation (CLTS) effort in our destination, Kasenga, Chongwe District. We made our way through several tarred and dusty roads to get there. On arrival, the locals welcomed us with delightful songs laced with clapping. As I watched the dedicated teams engage with the community, I learnt some very meaningful lessons.

Transparent dialogue:

When identifying issues that exist within a community, it is important that as many community members as possible be part of the discussion. This was clearly demonstrated when community members took part in mapping their locality to identify homes with toilets and those without. All present formed a circle around two young men who used a stick to draw a map of Kasenga. Stones marked homes and leaves were added if they had toilets. Despite my inability to understand Nyanja (the local language), it was evident that all community members were contributing to the process by pointing out any mistakes or omissions made by the amateur map-makers!

Walk of Shame:

Although “walk of shame” sounds negative in the context of community engagement, it does not have to be so. In this case, it means using the negative as a force for good. After the mapping of Kasenga settlement was completed, the village headman led the community members and all present in a walk of shame. This 2km long walk took us to innermost part of the settlement to look for and collect fresh stool. Once these ‘deposits’ were found, they were brought back to our starting point for all to behold in their glory while we discussed the hazardous effects of open air defecation. One of the community facilitators led the discussion and using some food and water, she demonstrated how easy it is for human waste to contaminate food and drink and cause life-threatening diarrhoea to children and adults. For the exercise, she shared freshly prepared fish and some water amongst everyone and then placed the remaining food next to the faecal deposits and we watched as flies danced between them. For the water, she used a piece of stick to poke the faeces and put it into the can of water. Then, she asked if we would like some fish or water. The response was a unanimous “No”. The Community Champion then asked all to imagine what happens in homes where people defecate outside and a hen, for instance, could poke it with its beak or touch it with its feet and then match into the kitchen and touch prepared food that will be eaten by the household. Needless to say, it was disgusting to discuss food and drink in the midst of the excreta, but it had the desired effect and drove the lesson home!

Improvise:

One of the community facilitators demonstrated how to make a simple handwashing facility called Tip Tap using a leaking can filled with water and some dry sticks. This amazing equipment can be built by anyone outside their toilet. Instead of soap, community members were encouraged to use ash as a cleaning agent for their hands. This innovation will make it easy for communities to adopt handwashing as it costs next to nothing!

Simple logic:

What followed after the collected waste was safely deposed of was a lesson led by one of the facilitators on the monetary cost of illness that result from contamination of food or water by human waste. Using a long sheet of white paper and a marker, we all estimated and compared the cost of seeking medical care at a health facility versus the cost of building a local toilet. Unassisted, the inhabitants of Kasenga were able to come to the conclusion that the cost of medical care was much higher.

So what do you think? Leave a comment to let us know any lessons you are learning from your work in the community. Also do not forget to share this post! Just click on any of the social media icons 🙂

The Zambian National Malaria Control Programme appears to be a growing success. Estimates from the Zambian Demographic Health Surveys indicate a 29% reduction in under-5 mortality for the period, 2001-2007. Even more, a research paper in the American Journal of Tropical Medicine and Hygiene highlights the improvements in household and individual adoption of malaria prevention tools such as insecticide treatment nets (ITN) and Intermittent preventive treatment in pregnancy (IPTp). By 2008, 60% of households in Zambia had at least one ITN and over 60% of pregnant women had received 2 or more doses of IPTp. However, an increase in malaria cases was reported in 2010.

Having read bits and pieces of Zambia’s efforts in combating malaria in the news media, I set out to understand and share, from public health literature, some of the factors that were responsible for their public health gains. In part 2, I will examine the implications of these factors, which I call the building blocks, and the challenges that lie ahead for Zambia and other African nations.

The Building Blocks

National Commitment

After the launch of the Roll Back Malaria Partnership in 1998, the Zambia Government put in place structures that demonstrated a commitment to the elimination of malaria. These included the establishment of a ministerial task force to coordinate the development of the 2000-2005 National Malaria Strategic Plan (NMSP) and the founding of the National Malaria Control Centre (NMCC) in 2002. The National Government also went ahead to eliminate taxation on ITNs and on corresponding insecticides while adopting artemesinin- based combination therapy (ACT) as its front-line anti-malaria therapy recommendation.

By 2005, the National Malaria Control Centre set out to reduce malaria incidence and under-5 mortality in five years by 75% and 20% respectively. These goals were set to be achieved through a combination of prevention strategies that included insecticide treated nets (ITN), indoor residual spraying (IRS) and prompt malaria diagnosis and treatment with Rapid Diagnostic Kits and artemesinin-based combination therapy (ACT). Coverage targets outlined in the 2006-2011 NMSP included: greater than 80% of households with an average of 3 ITNS/HH, greater than 80% of pregnant women receiving greater than or 2 doses of IPTp, greater than 80% of pregnant women sleeping under ITN or in a house with IRS, greater than 80% of children under 5 years sleeping under ITN or in a house with IRS and greater than 80% of sick persons treated with effective anti-malarial within 24 hours of onset.

To further along their goals to eliminate malaria, The Zambia Government also increased allocations for the malaria control initiatives. By 2008, budget allocations for malaria from the Zambia Government had come to $25.4 million.

These actions by the Government of Zambia provided evidence of its dedication to eliminating malaria and improving the health outcomes of Zambians.

International community support

Zambia’s efforts to build the infrastructure for national scale malaria control program attracted substantial donor support. Donors included the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM), the U.S Agency for International Development (USAID), the Bill and Melinda Gates Foundation through the Malaria Control and Evaluation Partnership in Africa (MACEPA), the World Bank, the U.S President Malaria Initiative (PMI), and the World Health Organization. Donations from these international organizations combined with domestic funds from the Zambian Government ensured that crucial aspects of the malaria control program were funded.

However, support for malaria control initiative in Zambia was also the result of a desire by the international community to have a successful model of a national scale malaria control initiative which can be replicated by other countries within the region.

Staying the course

From 2002, Zambia began a nation-wide roll out of insecticide treated nets (ITNs), indoor residual spraying (IRS) and Rapid diagnostic Tests (RDTs) kits. In the following years, efforts were made to expand the distribution of these key aspects of the malaria control program to ensure adequate population coverage. However, the inconsistent nature of donor funding impacted the distribution of bed nets for years 2004 and 2008.

Rollout of ITNs, IRS and RDTs at the National Level

Source: National Bureau of Economic Research

To ensure access to treatment for diagnosed malaria cases, ACTs were made free to all those seeking care within the public health sector.

Data-Informed Decision-Making

Using the National Health Management Information Systems as well as sentinel surveys like the Zambian Demographic and Health Survey (ZDHS) and the Malaria Indicators Surveys, the Zambian Government and its International partners were able to monitor the progress of the nation-wide malaria control efforts.

Some data points captured by these data tracking tools include under-five child malaria mortality, yearly malaria in-patients from all facilities, and distribution, ownership and use of ITNs.

Climatic Advantages

Zambia has 3 distinct seasons within its tropical climate-a hot, rainy season (November-April), a cool dry winter (May-August), and a hot, dry season (September-October). These seasonal variations influenced the transmission of malaria by Plasmodium infected mosquitoes. Mosquitoes were abundant from September to April but markedly reduced during the cold winters from May to August. As a result, efforts to reduce population malaria parasitemia during those winter months may induce reduced transmission during the other months.

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Global Health Africa was created by two global health professionals – Sophie Okolo and Ifeoma Ozodiegwu – in 2012. With a focus on Africa, these two global health enthusiasts spotlighted unexplored health issues such as autism, elderly abuse, dementia, and neglected tropical diseases on the blog. As their interests evolved, Sophie and ... Continue reading →